Eli's Rehab Report

Published on Thu May 24, 2012 PDF

The following Q&As have been provided by Rick Gawenda, PT, president of Gawenda Seminars & Consulting Inc.

Question: When you are currently treating a patient for one condition and while still treating the first condition, the patient presents with a new referral for another condition, should I bill an evaluation or re-evaluation?

Answer: Scenario 1: When condition B is related to condition A, then the appropriate code to bill for the evaluation service provided is a re-evaluation.

Example: A patient is receiving treatment for a total knee arthroplasty (TKA). During the episode of care, the patient develops wrist pain. The clinician determines the pain is due to use of a walker, which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition related to the TKA. Therefore, it is appropriate for the clinician to provide a re-evaluation of the patient due to this related condition.

Scenario 2: When condition B is not related, directly or indirectly, to condition A, then the evaluation of condition B would warrant billing for a new evaluation.

Example: A patient is receiving treatment following a TKA. During the episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines the rotator cuff injury is not related to the TKA. Therefore, it is appropriate for the clinician to provide a new evaluation for the rotator cuff injury since it a newly identified diagnosis for an unrelated condition.

In either case, it is necessary for the documentation to accurately support the services provided. Please keep in mind that a patient's insurance benefit may limit the number of evaluations and/or re-evaluations that the insurance carrier will reimburse for in a calendar year or in a specific time frame.

Question: Can a physical therapist, occupational therapist, or speech-language pathologist evaluate and treat a patient referred by an out of state physician or non-physician practitioner (NPP)?

Answer: The answer depends on your state practice act and administrative rules as well as the insurance company's policies regarding the need for physician orders, who can write them, and whether the physician/NPP who ordered the therapy services can be from out of state.